Concussion

Thoughts on Sports Related Concussions

The updated consensus statement on concussions in sport was published in the British Journal of Sports Medicine. For those working with athletes, it is important to read through the entire consensus statement. The following are a few points of interest from the consensus statement (in bold) and my thoughts after in blue.

Sports related concussion is a traumatic brain injury induced by biomechanical forces. Several common features that may be utilized in clinically defining the nature of a concussive head injury include:

  • SRC may be cause neither by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.
  • SRC typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.
  • SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
  • SRC results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged.

A direct blow to the head or neck region is not necessary for an athlete to suffer a sports related concussion (SRC). The blow can be to anywhere on the athlete as long as the force is transmitted to the head region. 
Although an athlete may appear okay after initial impact, the athlete should still be monitored because the symptoms may progress over several minutes to hours after an injury.
As mentioned in previous consensus statements, the loss of consciousness is not necessary for a SRC and is not present in majority of SRCs.



In all suspected cases of concussion, the individual should be removed from the playing field and assessed by a physician or licensed healthcare provider. A player with a diagnosed SRC should not be allowed to return to play on the day of injury.
While this has been included in previous consensus statements, it is necessary to repeat. If an athlete is suspected to have suffered a concussion, the athlete should be removed and assessed by a qualified medical professional. A previous history of a SRC is a risk factor of suffering another SRC and is also associated with longer term symptoms. 



The SCAT is useful immediately after injury in differentiating concussed from non-concussed athletes, but its utility appears to decrease significantly 3-5 days after injury.
For proper management of SRC, athletes should be assessed as soon as possible after an injury. The SCAT5 can be used as part of the management of an athlete with a SRC, but a “normal” SCAT doesn’t mean that they athlete does not have a SRC or is cleared to return to sport.



The player should not be left alone after the injury, and serial monitoring for deterioration is essential over the initial few hours after injury.
As mentioned above, the symptoms can progress following an injury so monitoring the athlete for the development of these symptoms is critical. 



After a brief period of rest during the acute phase (24-48 hours) after injury, patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom-exacerbation thresholds.
Previous concussive statements recommended an athlete rest until they were completely symptom-free before beginning activity. The current guidelines suggest a brief period of rest then gradually increasing the activity of the athlete while monitoring symptoms. 



Treatment should be individualized and target-specific medical, physical, and psychosocial factors identified on assessment. There is preliminary evidence supporting the use of:

  • An individualized symptom-limited aerobic exercise program in patients with persistent post-concussive symptoms associated with autonomic instability or physical de-conditioning, and
  • a targeted physical therapy program in patients with cervical spine or vestibular dysfunction, and
  • a collaborative approach including cognitive behavioral therapy to deal with any persistent mood or behavioral issues.

The treatment of concussion can be a frustrating experience for athletes. Finding aerobic activities that the athlete can perform without symptoms can be a helpful strategy for recovery.



For most injured athletes, cognitive deficits, balance and symptoms improve rapidly during the first 2 weeks after injury. At present, it is reasonable to conclude that the large majority of athletes recover, from a clinical perspective, within the first month of injury.
Recovering from a SRC doesn’t have to do with mental toughness. The brain takes time to recover, with 2-4 weeks being about the average recovery time. However, recovery time will vary between each individual athlete. 



Multiple studies suggest physiological dysfunction may outlast current clinical measures of recovery, supporting a ‘buffer zone’ of gradually increasing activity increasing activity before full contact risk.
Just because an athlete is symptom-free does not necessarily mean that they have completely recovered from a SRC. A gradual progression back to contact sport is necessary and the athlete should be monitored throughout the progression.

It is essential that we can recognize and evaluate when an athlete is suspected of having a sports related concussion. For coaches, trainers, and healthcare professionals, it is encouraged to read the full consensus statement on concussion in sports


Resources:
McCrory P, Meeuwisse W, Dvorak J, et al Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016 Br J Sports Med Published Online First: 26 April 2017. doi: 10.1136/bjsports-2017-097699

Sport concussion assessment tool – 5th edition Br J Sports Med Published Online First: 26 April 2017. doi: 10.1136/bjsports-2017-097506SCAT5